On August 2, 2014, 75 workers were killed and about 186 were injured by an explosion at an auto parts factory in Kunshan, China. This devastating event has raised questions about worker protection and oversight in China, as well as the responsibility for manufacturers using subcontractors in China to provide a safe workplace.
The explosion can be examined in a Cause Map, or visual root cause analysis, to look at the effects, causes, and potential solutions of the issue. A Cause Map visually diagrams the cause-and-effect relationships associated with an issue. The first step in the Cause Mapping process is to determine the impact on an organization’s goals. In this case, the goals will be looked at from the broader perspective of the country of China. The safety goal was impacted due to the large number of fatalities and injuries. The regulatory goal is impacted due to the five executives that were detained (though it’s unclear for what purpose they are being held). In the wake of the disaster, 268 factories in the surrounding area have been shut down (impacting the production goal) as part of a three-month round of inspections (an impact to the labor goal). In addition, the property goal was impacted due to the damage to the factory, the full extent of which is still unknown.
The cause-and-effect relationships resulting in these impacts to the goals are developed by asking ‘Why’ questions. The fatalities, injuries and damage to the factory resulted from an explosion. Preliminary investigation shows that it was a metal dust explosion. Dust explosions require five components to occur (as described in the dust explosion pentagon). These components are: heat, fuel, oxygen, confinement and dispersion. Oxygen and confinement are present under normal conditions. The preliminary investigation has identified a spark as the heat source (a common potential heat source in industrial settings).
In the case of a dust explosion, the fuel source is a dust, which is distributed into the air, providing a high level of surface area allowing the fuel to become explosive (dispersion). The process being performed at the plant, which manufactures wheels for a car manufacturer, was electroplating/ polishing hubcaps. At the time, the workers were polishing hubcaps, a process that is known to create metal dust that can lead to dust explosions if safety regulations aren’t carefully followed. Specifically, safety regulations protecting against dust explosion involve cleaning and ventilation. The preliminary investigation found a shortage of equipment that is used to remove dust.
Unfortunately, that’s not too surprising. Industrial accidents kill tens of thousands of people a year in China, which has generally demonstrated a lack of regard for safety. Regulations involving dust are insufficient (and insufficiently enforced) by both the government and the manufacturing companies that subcontract work to Chinese firms (and generally outsource oversight to their contractors). Subcontractors who make small, low-value parts find themselves under heavy pressure to cut costs in a competitive market. According to Geoffrey Crothall of the China Labor Bulletin, “The explosion at the factory in Kunshan illustrates once again that although there are many laws and regulations outlining health and safety standards in the workplace those standards are not properly enforced by local authorities.”
In response to the explosion, China has detained executives from the company, and has closed 268 factories that have the potential for similar issues until they are given government permission to reopen. The government is conducting what is expected to be a three-month round of investigations of these factories and is expected to develop regulations that will better protect workers from explosive dust conditions.
The incident is drawing comparisons to the Triangle Shirtwaist Company fire in New York City which killed 146 workers in 1911. After the deadly fire, many protections were put into place that have increased workplace safety in the United States. It is hoped this tragedy will lead to a similar outcry that will force the government to act on increasing worker safety and produce lasting change.
To view the Outline and Cause Map based on the preliminary investigation, click on “Download PDF” above. Or, click here to learn more about dust explosions.